ATI Respiratory Post Test
a nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor vehicle crash. which of the following findings is an indication of pneumothorax?
client is experiencing unequal movement of posterior chest
a nurse is assessing a client who is dark skinned. which of the following areas of the client's body should the nurse assess the client for adequate oxygenation?
-nail beds -oral mucosa -lips
a charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. which of the following descriptions should the nurse use to describe a pleural friction rub?
-coarse grating rub -heard on inspiration and expiration -pain with breathing
a nurse is auscultating the lateral lobe of a client who has bronchitis and hears a whistling, high pitched musical sound. the nurse should document the sound as which of the following?
wheezing
a nurse is performing a head to toe assessment of a client. which of the following findings indicate the client might be experiencing respiratory difficulty?
-client is sitting in tripod position -client is using pursed lipped breathing -client appears confused
a nurse is preparing to auscultate a client's posterior and lateral chest. in which order should the nurse perform the following actions?
-expose the posterior chest with client sitting with arms folded across chest -auscultate 8 cm to one side of spine around C7 then auscultate the other side same location -auscultate down spin moving from side to side till thoracic spin is reached -auscultate lateral sides slightly below axillary area then down to seventh or eighth rib
a nurse is caring for a client who is experiencing episodes of hyperventilation. which of the following manifestations should the nurse expect during hyperventilation?
-numbness and tingling of extremities -lightheadedness -chest pain
a nurse is admitting a client who has a new diagnosis of COPD. which of the following information documented by the nurse is subjective?
-report from client says they sleep while propped on two pillow at night -client says they quit smoking 2 years ago -client states "being short of breath all of the time is making me depressed"
a nurse is providing teaching to a client who has a new diagnosis of asthma and reports a smoking history of 20 years. which of the following statements should the nurse make when counseling the client about their tobacco use?
-smoking is linked to various forms of cancer -it might take several attempts to finally stop smoking -there are pharmacologic therapies that can help a person stop smoking
a nurse is reviewing the medical record of a client who was assessed as having a barrel chest resulting from COPD. which of the following description is true of barrel chest?
anterior/posterior to transverse ration is equal (AP:T diameter = 1:1)
a nurse is caring for a client who is dying and is having period of deep breathing alternating with period of apnea. the nurse should identify this as what type of breathing?
cheyne stokes breathing
a charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
clubbing of the fingers indicates a chronic state of impaired perfusion
a nurse is caring for a client who is having difficulty breathing. which of the following actions should the nurse take first?
elevate the head of the client's bed
a charge nurse is reviewing the documentation of a newly licensed nurse. which of the following entries made by the newly licensed nurse is an example of correct documentation?
inspiratory wheeze auscultated at laeft lateral chest
a nurse is auscultating the breath sounds of a client who has pneumonia and hears bronchial crackles. in which of the following areas of the chest is the nurse auscultating.
sort of the throat
a charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. for which of the following actions should the charge nurse intervene.
the nurse is auscultating through the clients gown
a nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. which of the following statements should the nurse make?
you should make every effort to receive a flu vaccine every year
